medicare secondary payer questionnaire (mspq)medicare secondary payer questionnaire (mspq) riverside...

Date Last Revised: 11/15/2019 9:54:04 AM 1

Medicare Secondary Payer Questionnaire

(MSPQ)

Medicare Secondary Payer Questionnaire (MSPQ) ............................................................................................. 2

Accessing the MSPQ ............................................................................................................................................. 2

MSPQ Explained ................................................................................................................................................... 4

Common MSPQ Situations of Primary vs. Secondary Payor Responsibility ........................................................ 4

MSPQ Explained ................................................................................................................................................... 8


Medicare Secondary Payer Questionnaire (MSPQ) Riverside uses the Medicare Secondary Payer Questionnaire or MSPQ as a guide to help identify other payers that may be primary to Medicare. Filling out the MSPQ can automatically change filing order in Epic so it is important to always fill out the MSPQ accurately and appropriately for each encounter. The registrars MUST complete the MSP questions on ALL Medicare patients. The patient is the preferred source for answering the MSPQ questions. If the patient is unable to answer, another source is acceptable who is familiar with the patient or reason for the visit. ***Please note that this questionnaire was developed by CMS to be used in sequence. Instructions are listed after the questions to facilitate transition between questions. The instructions will direct the patient to the next appropriate question to determine MSP situations.***

If the registrar is unable to complete the MSP questions at any point during the registration process, a "pop

up" will occur when trying to exit the MSPQ. The "pop up" reads: The MSPQ is incomplete for this encounter. Please return to the MSPQ to enter more information or select a reason for leaving the MSPQ incomplete at this time.

Once a registrar has entered the MSPQ to answer questions the only way to exit without completing is to give a reason. This is a hard stop.

Once a reason is entered the system will allow you to leave the MSPQ incomplete and close, in order to return to the rest of the registration. It is the registrars responsibility to research the answer needed to complete the questionnaire otherwise it will appear in a Workqueue.

MSPQ retirement dates will pull forward in the EPIC application but it is still very important to verify this date with the patient and update any information as necessary at each registration.

Accessing the MSPQ When to access the MSPQ:

The MSPQ will be automatically triggered by Epic when a patient has Medicare coverage and may show a task on the checklist in the registration or you can select MSPQ on the activity toolbar to access it. The View MSPQ button on the activity toolbar opens the MSPQ is read-only mode.


1. The MSPQ should be filled out for patients that have Medicare at each visit; if the patient has had the MSPQ filled out that day already, you will receive this pop up:

a. You can either say “Yes” to review and edit the MSPQ. b. You can say “No” and go to the View MSPQ button and simply review the MSPQ with the

patient for any changes. 2. You should never fill out the MSPQ or any other form with the answers you “think” are correct for a

patient; this form is legally required and answering the questions incorrectly is fraudulent per federal government regulations.

Where to access the MSPQ:

When you are registering the patient you will see the MSPQ button in the activity toolbar. A task may also be

created in the checklist when the MSPQ completion is necessary.

How to view the completed MSPQ:

When you are registering the patient you will see the View MSPQ button in the ED Update banner.

You can see in the right top of the document the completion date; you need to review the MSPQ with the

patient with each visit.


MSPQ Explained

Part 1:

1. Are you receiving Black Lung (BL) Benefits?

2. Are the services to be paid by a government research program?

3. Are you entitled to benefits through the Department of Veterans Affair (DVA)?

4. Was the illness.injury due to a work-related accident/condition?

Part II:

1. Was the illness/injury due to a non-work-related accident?

2. Is no-fault insurance available?

a. Is additional no-fault insurance available?

3. Is liability insurance available?

a. Is additional liability insurance available?

Part III:

1. Are you entitled to Medicare based on Age?

2. Are you entitled to Medicare based on Disability?

3. Are you entitled to Medicare based on End-Stage Renal Disease (ESRD)?

Part IV – AGE:

1. Are you currently employed?

a. If applicable, date of retirement:

2. Do you have a spouse who is currently employed?


3a. Do you have a group health plan (GHP) coverage based on your own current employment?

3b. Do you have a group health plan (GHP) coverage based on your spouse’s current employment?

4. If you have a GHP coverage based on your own current employment, does your employer that sponsors

or contributes to the GHP employ 20 or more employees?

5. If you have a GHP coverage based on your spouse’s current employment, does your spouse’s employer,

that sponsors or contributes to the GHP, employ 20 or more employees?

Part V - DISABILITY:

1. Are you currently employed?



2. Do you have a spouse who is currently employed?


3a. Do you have a group health plan (GHP) coverage based on your own current employment?

3b. Do you have a group health plan (GHP) coverage based on your spouse’s current employment?

4. Are you coverage under a GHP based on the current employment of a family member other than a

spouse?

5. If you have a GHP coverage based on your own current employment, does your employer that sponsors

or contributes to the GHP employ 100 or more employees?

6. If you have a GHP coverage based on your spouse’s current employment, does your spouse’s employer,

that sponsors or contributes to the GHP, employ 100 or more employees?

7. If you have a GHP coverage based on a family member’s current employment, does your family

member’s employer, that sponsors or contributes to the GHP, employ 100 or more employees?

Part VI – ESRD:

1a. Do you have a GHP coverage based on your own current or former employment?

1b. Do you have a GHP coverage through your spouse?

1c. Do you have GHP coverage through a family member other than your spouse?

2. Have you received a kidney transplant?

3. Have you received maintenance dialysis treatments?

a. Have you participated in a self-dialysis training program?

4. Are you within the 30-month coordination period?

5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability?

6. Was your initial entitlement to Medicare (including simultaneously or dual entitlement) based on

ESRD?

7. Does the working aged or disability MSP provision apply (i.e. is the GHP already primary based on age

or disability entitlement?

Common MSPQ Situations of Primary vs. Secondary Payor

Responsibility

The following list identifies some common situations when Medicare and other health insurance or coverage

may be present, and which entity will be the primary or secondary payer.

1. Working Aged (Medicare beneficiaries age 65 or older) and Employer Group Health Plan (GHP):


Individual is age 65 or older, is covered by a GHP through current employment or spouse’s current

employment AND the employer has less than 20 employees:

Medicare pays Primary, GHP pays secondary

Individual is age 65 or older, is covered by a GHP through current employment or spouse’s current

employment AND the employer has 20 or more employees (or at least one employer is a multi-employer

group that employs 20 or more individuals):

GHP pays Primary, Medicare pays secondary

Individual is age 65 or older, is self-employed and covered by a GHP through current employment or

spouse’s current employment AND the employer has 20 or more employees (or at least one employer is a

multi-employer group that employs 20 or more individuals):


2. Disability and Employer GHP:

Individual is disabled, is covered by a GHP through his or her own current employment (or through a family

member’s current employment) AND the employer has 100 or more employees (or at least one employer is a

multi-employer group that employs 100 or more individuals)


3. End-Stage Renal Disease (ESRD):

Individual has ESRD, is covered by a GHP and is in the first 30 months of eligibility or entitlement to

Medicare

GHP pays Primary, Medicare pays secondary during 30-month coordination period for ESRD

Individual has ESRD, is covered by a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA

plan) and is in the first 30 months of eligibility or entitlement to Medicare

COBRA pays Primary, Medicare pays secondary during 30-month coordination period for ESRD

Please see the ESRD page for more information.


4. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – the law that provides continuing

coverage of group health benefits to employees and their families upon the occurrence of certain

qualifying events where such coverage would otherwise be terminated.

Individual has ESRD, is covered by COBRA and is in the first 30 months of eligibility or entitlement to

Medicare

COBRA pays Primary, Medicare pays secondary during 30-month coordination period for ESRD

Individual is age 65 years or older and covered by Medicare & COBRA:

Medicare pays Primary, COBRA pays secondary

Individual is disabled and covered by Medicare & COBRA:

Medicare pays Primary, COBRA pays secondary

5. Retiree Health Plans

Individual is age 65 or older and has an employer retirement plan:

Medicare pays Primary, Retiree coverage pays secondary

6. No-fault Insurance and Liability Insurance

Individual is entitled to Medicare and was in an accident or other situation where no-fault or liability

insurance is involved.

No-fault or Liability Insurance pays Primary for accident or other situation related health care

services claimed or released, Medicare pays secondary

7. Workers’ Compensation Insurance

Individual is entitled to Medicare and is covered under Workers’ Compensation because of a job-related

illness or injury:

Workers’ Compensation pays Primary for health care items or services related to job-related illness

or injury claims. Medicare generally will not pay for an injury or illness/disease covered by workers’

compensation. If all or part of a claim is denied by workers’ compensation on the grounds that it is not


covered by workers’ compensation, a claim may be filed with Medicare. Medicare may pay a claim that

relates to a medical service or product covered by Medicare if the claim is not covered by workers’

compensation. Prior to settling a workers’ compensation case, parties to the settlement should consider

Medicare’s interest related to future medical services and whether the settlement is to include a Workers’

Compensation Medicare Set-aside Arrangement (WCMSA).

Note: When there is evidence that the no-fault insurer, liability insurer, or workers’ compensation plan will not

pay promptly, Medicare may make a conditional payment. A conditional payment is a payment Medicare makes

for services another payer may be responsible for. Medicare makes this conditional payment so that the

beneficiary won’t have to use his own money to pay the bill. The payment is “conditional” because it must be

repaid to Medicare when a settlement, judgment, award or other payment is made.

Federal law takes precedence over state laws and private contracts. Even if an entity believes that it is the

secondary payer to Medicare due to state law or the contents of its insurance policy, the MSP provisions would

apply when billing for services.

MSPQ Epic Example

The answers to the MSPQ can change filing order for a patient’s coverages automatically. Below is a scenario

of how and when this can occur.

Patient is retired, has coverage with BCBS through the marketplace, has Medicare due to age and his wife is

actively working and has coverage that carries the patient.

a. Before the MSPQ is filled out the coverages are in this order:


b. With the MSPQ filled out correctly the order of the coverages changes because the patient’s wife’s

coverage through her employer has more than 20 employees.

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